Adult survivors of childhood abuse have higher rates of illness than are found among the general population—often debilitating illnesses accompanied by chronic pain. Some standard medical treatments are likely to be difficult for survivors, and can even re-traumatize them. Now professionals can turn to this comprehensive resource to get practical advice on working with these challenging and vulnerable patients and specific guidelines for treating the three most common symptoms encountered in health care settings: depression, PTSD and chronic pain.

Get answers to critical questions like these:

• Why and how should clinicians in a primary care setting screen for and treat depression, PTSD and chronic pain?
• What is the link between past abuse and current pain?
• How is past childhood abuse linked to the most common causes of death in adults?
• Why are the healthcare costs of abuse survivors are higher than those of the general public?
• Why are abuse survivors more likely to participate in high-risk sex?
• How can clinicians take care of themselves when working with traumatized patients?
• Which standard medical procedures are more likely to traumatize patients who are abuse survivors?
• Why are a patient’s thoughts and beliefs important in the development of illness?
• What are the AMA Guidelines on treating patients with a trauma history, without further traumatizing them?
• What gastrointestinal symptoms are most common in abuse survivors?
• Why are patients who are hostile or mistrusting more likely to have coronary heart disease?
• When childhood abuse has impact a person’s faith or belief in God, what are the implications of that for health?

Table of Contents

About the Author

Foreword

Preface

Chapter 1: Abuse Survivors in the Health Care System

The Health of Adult Survivors

Patterns of Health Care Use

Doctors’Visits

The Impact of Severity

Symptoms, Surgery, and Disability

Increased Health Care Costs

Depression

Posttraumatic Stress Disorder

Pain

Why Child Abuse Makes People Sick

Chapter 2: Physiological Pathways

The Brain and Nervous System

Brain 101

Brainstem Nuclei

The Stress Response

Sensory Intake and Interpretation of the Environment

Generation of Emotions Based on the Appraisal Processes

Initiation of Autonomic and Endocrine Responses

Autonomic and Endocrine Outflow

Neuronal Plasticity

Sensitization

Changes in the HPA Axis

Evidence for HPA Alterations and Sensitization

Animal Studies

Studies of Infants

Studies of Children

Summary

Chapter 3: Behavioral Pathways

Substance Abuse

Representative Sample of Adults

Samples From Primary Care Medical Practices

Samples From Treatment Programs

Samples With Children or Teens

Other Clinical Populations

Prospective Designs

Possible Explanations for Substance Abuse in Adult

Survivors

Psychosocial Explanations

Biological Vulnerability

How Substance Abuse Affects Health

Smoking

Why Abuse Survivors Smoke

How Smoking Affects Health

Obesity and Eating Disorders

Obesity

Eating Disorders

Theories for Eating Disorders in Abuse Survivors

How Obesity and Eating Disorders Impact Health

Suicide

Relationship Between Abuse and Suicide

The Health Effects of Suicide Attempts

High-Risk Sexual Behavior

High-Risk Sexual Activity Among Special Populations

Theories Explaining High-Risk Sexual Behavior

Cognitive Aspects of High-Risk Sex

Social Learning Theory

Health Effects of High-Risk Sexual Activity

High-Risk Behaviors in Combination

Health-Promoting Behaviors

Sleep

Possible Mechanisms for Sleep Disturbances

Perfectionism and Parental Criticism

Anxiety

Depression

PTSD

How Sleep Affects Health

Summary

Chapter 4: Cognitive Pathways I—Beliefs About Self

Shame and Self-Blame

Shame

Self-Blame

Studies With Teens and College Students

Studies With Adults

Health Effects of Shame and Self-Blame

Attributional Style

Impact of Abuse on Attributional Style

How Attributional Style Influences Health

Health Perception

Health Effects of Health Perception

Health Locus of Control

Self-Esteem and Self-Efficacy

Self-Esteem Influenced by Childhood Abuse

Self Efficacy Influenced by Childhood Abuse

Health Effects of Self-Esteem/Self-Efficacy

Adaptation to Disability

Compliance With Treatment

Health Behaviors

Self-Efficacy and Parenting

Summary

Chapter 5: Cognitive Pathways II—Cognitions About Others

Internal Working Model

Mistrust and Hostility

Mistrust

Hostility

Health Effects of Mistrust and Hostility

Rejection Sensitivity

Rejection Sensitivity and Current Relationships

Rejection Sensitivity and Health

Dependency

Religiosity

Impact of Past Abuse on Religious Faith

Religion and Health

How Religion Can Positively Influence Health

How Religion Can Negatively Influence Health:

Anger at God

Forgiveness

Hope

Impact of Abuse in Hope

Hope and Health

Summary

Chapter 6: Social Pathways I—Social Networks, Support, and Relationships

Attachment Theory Revisited

Insecure Attachments

Abuse as Predictor of Attachment Style

Health Effects of Insecure Attachment

Quality of Current Primary Intimate Relationship

Divorce

Social Isolation

Impact of Relationships on Health

Social Support Buffers Stress

Marriage, Marital Strife, and Health

Social Isolation and Health

Childhood Abuse and Interpersonal Style

Dysfunctional Interpersonal Styles

Relationship of Interpersonal Style to Health

Unmitigated Communion

Caretaking

Attachment Style

Relationships

Why Social Support Is Sometimes Stressful

Summary

Chapter 7: Social Pathways II—Poverty, Homelessness, and Revictimization

Socioeconomic Status

Difficulties in School

Learning Difficulties in Adults

SES and Health

Unhealthy Behavior

Psychosocial and Psychobiological Factors

Homelessness

History of Adverse Experiences

Teens and Homelessness

Health Implications of Homelessness

Revictimization

During Childhood

Of Young Adults and College Students

Of Adults

Community Samples

Clinical Samples

Family Dysfunction Increases Risk

Revictimization in Ethnic-Minority Populations

Theories of Revictimization

Revictimization and Health

Summary

Chapter 8: Emotional Pathways—Posttraumatic Stress Disorder

Depression and Abuse Survivors

Prevalence

Co-Occurring Depression and Substance Abuse

Is Child Sexual Abuse Uniquely Harmful?

The Biology of Depression

Sensitization and Depression

Depression and HPA Alterations

Cholinergic Pathways in Depression

Depression and Cytokine Activity

How Depression Influences Health

Depression and Cardiovascular Health

Depression and Immune Function

Depression and Health Behaviors

Depression and Increased Vulnerability

Posttraumatic Stress Disorder

The Biology of PTSD

Dysregulation of Stress Response

Effects of PTSD on the Brain

How PTSD Affects Health

Mechanisms by Which PTSD Influences Health

PTSD and Comorbidity

PTSD and Reactivity

PTSD and Sleep Quality

PTSD and Health in Aging Trauma Survivors

PTSD vs. Depression

Summary

Chapter 9: Individual Differences in the Expression of Symptoms

Timing of Abuse, Brain Maturation, and Appraisal of Events

Brain Maturation

Critical Periods of Brain Development

Sensitization Revisited

Appraisal

Characteristics of the Abuse

Identity of the Perpetrator

Severity of Abusive Acts

Duration and Force

Ethnic Group Differences in How Abuse Is Experienced

Sex of Subject and Symptomatology

Quality of the Family of Origin

Independent Effects of Abuse vs. Family Dysfunction

Family Dysfunction Compounds Effects of Abuse

Family Dysfunction Also Increases the Risk of Abuse

Summary

Chapter 10: Chronic Pain in Abuse Survivors

The Enigma of Chronic Pain

Difficulties in Diagnosis and Treatment

Functional vs. Organic Conditions

The Pain-Abuse Connection

Psychiatric Comorbidity in Pain Patients

Explanations for Psychiatric Diagnoses in Functional Illness

Chronic Pain vs. Somatization

Treatment Impact of Somatization

Neurological Mechanisms in Pain

Brain Structures in Pain

Changes in the Pain Threshold

Chronic Pain Syndromes in Adult Survivors of Childhood Abuse

Back Pain

Headaches

Pelvic Pain and Other Gynecological Conditions

Pelvic Pain

Other Gynecological Conditions

Fibromyalgia Syndrome

Effects of Past Abuse on Development of FMS

Pathophysiology of Fibromyalgia

Sleep Problems in Fibromyalgia

Irritable Bowel Syndrome

A Diagnosis of Exclusion Associated With a History of Abuse

Some Theories of Irritable Bowel Syndrome

What We Know About Pain and Abuse

Pain Syndromes Co-Occur

Pain Syndromes Have Commonalities

We Still Cannot Prove That Abuse Causes Chronic Pain

Summary

Chapter 11: Clinical Approaches to Abuse Survivors in Health Care Settings

When to Suspect Past Abuse

How to Inquire About Past Abuse

Routine Screening

Clinician Concerns When Screening

Why Abuse Survivors May Deny Abuse

Trust Issues

Possible Amnesia

Handling Abuse History When Patients Share It

Charting Abuse Information

Maintaining Confidentiality

Assessing Current Patient Safety

Other Legal Obligations

Duty to Report

Duty to Warn

Treating Without Traumatizing: Approaches to Patients in Medical Settings

Using a Medical/Mental Health Team Approach to Care

Finding Clinicians in the Community

Identifying Comorbid Psychological Conditions

Use of Support Groups

Summary

Chapter 12: Clinical Management of Depression in Health Care Settings

Assessment of Patients for Depression

Depressive Symptoms

Diagnostic Criteria for Major Depression

Risk Factors for Depression

Past Depression

Current Stressors

Family History

Lack of Social Support

Psychiatric and Physical Comorbidity

Assessing Active Substance Abuse

Assessing Suicide Risk

Assessing the Need for Psychiatric Hospitalization

Treatment With Antidepressant Medications

Major Types of Antidepressants

Tricyclics

Selective Serotonin Reuptake Inhibitors

MAOIs

Phases of Depression Management With Medication

Acute Phase

Continuation Phase

Maintenance Phase

Antidepressants and Breastfeeding Mothers

Cognitive-Behavioral Therapy

Efficacy of CBT for Abuse Survivors

Alternative Treatment Approaches

Supplements

Exercise

St. John’s Wort

Summary

Chapter 13: Clinical Management of Posttraumatic Stress Disorder

Diagnosis of PTSD

Initial Screening

Diagnostic Criteria for PTSD

Complex PTSD

Treatment

Patient Education

Normalization

Removing Self-Blame and Self-Doubt

Correcting Misunderstandings

Clinician Credibility

The Efficacy of Patient Education

Peer Counseling

Psychotherapy

Cognitive-Behavioral Therapy

Eye Movement Desensitization and

Reprocessing

The Efficacy of Psychotherapy

Medications

Antidepressants

Benzodiazepines

Adrenergic Agents

Anticonvulsants

Phases of Treatment With Medications

Summary of Treatment for PTSD

Chapter 14: Basic Pain Management in a Health Care Setting

Why Pain Is Difficult to Treat

Management of Chronic Pain

Assessment

Treatment Team

Barriers to Treatment

Pharmacological Treatment of Chronic Pain

Non-Steroidal Anti-Inflammatory Drugs

Narcotics

Antidepressant Medications

Nonpharmacological Management of Chronic Pain

Relaxation Techniques

Progressive Muscle Relaxation

Biofeedback

Cognitive Aspects of Pain Management

Patient Education

Pain Diary

Activity Pacing

Pleasant-Activity Scheduling

Addressing Beliefs About Pain

Reframing or Cognitive Restructuring

Physical Treatments

Physical Therapy

Chiropractic and Acupuncture

Practitioner Misbeliefs About Chronic Pain

Some Final Suggestions for Clinicians

Summary

Epilogue

Table of Acronyms

Appendix A: Treatment of Traumatized Children

Appendix B: Online Resources for Depression

Appendix C: Online Resources for Posttraumatic Stress Disorder

Appendix D: Online Resources for Pain

Appendix E: Clinical Self-Care

Appendix F: Bibliography

Index